The risk of giving birth to a stillborn child or a child with severe congenital anomaly is higher for women who have immigrated to Europe as compared to the majority population in the receiving country. The literature, however, reveals great differences between migrant groups, even within migrants from low-income countries, although there is no clear pattern regarding refugee or non-refugee status. This heterogeneity argues against a particular migration-related explanation.
There are social disparities in stillbirth risk worldwide, and it has been suggested that the demonstrated ethnic disparity is a result of the socioeconomic disadvantage most migrants face. Consanguinity has been considered as another cause for the increased stillbirth risk and the high risk of congenital anomaly observed in many migrant groups. Utilization and quality of care during pregnancy and childbirth is the third major aspect. All three factors seem to contribute to stillbirth risk, and they should be considered in clinical practice and public health.
Highlights
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Pregnant women in Europe with a migrant background are at a higher risk of giving birth to a stillborn child or a child with a congenital anomaly than indigenous women are. The heterogeneity in risk between different migrant groups points toward mechanisms beyond migration per se and socioeconomy.
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In order to reduce the risk of stillbirth and having a child with a congenital anomaly for all women, we need to gain insight into the mechanisms that create the disparities, and we need to study both migrant groups with adverse and favorable reproductive health outcomes.
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Currently, the risk factor profile for stillbirth and congenital anomalies differs between different ethnic groups, and the antenatal and birth care systems need to consider this when evaluating the risk for an individual woman.
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Specific risk factors for migrant women including adverse socioeconomic position, consanguinity, emotional strain due to isolation, and hostility or discrimination, and, in the case of refugees, posttraumatic stress disorder (PTSD) victims in the household have to be considered.
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For public health and the health-care system, efforts to start antenatal care at an early stage, provision of early prenatal screening for congenital anomalies, information to young people about risk factors for stillbirth and congenital anomalies, including prepregnancy folic acid supplementation and consanguinity, are essential, along with improvement in health literacy for women and professionals in antenatal and perinatal care.
Introduction
In a landmark systematic review and meta-analysis of perinatal health in migrants to Western countries, it was demonstrated that migrants from Africa, the Middle East, and Asia had higher feto-infant mortality than mothers in the receiving countries, although the picture was mixed in the case of gestational age at birth, fetal growth, and healthy lifestyle during pregnancy .
Stillbirth is a serious health outcome and an important health indicator. Even in high-income countries, the risk of intrauterine death in the third trimester is at the same level as the mortality risk for men and women above 80 years of age, and stillbirth is a traumatic experience for parents . Huge variation in stillbirth risk between countries and populations indicates that a considerably large proportion of stillbirths are preventable . Stillbirth rates are decreasing worldwide because of many reasons reflecting the complex causal nature of stillbirth. Some stillbirths are attributed to birth and antenatal care, some to poverty and individual risk factors, and some to the existing illness of the fetus (that may also be preventable), and a large proportion of stillbirths are still unexplained .
Between 10% and 20% of stillborn children have congenital anomalies , and the literature review indicated that migrant women had worse outcomes than majority populations in terms of congenital anomalies , but due to the heterogeneity of the outcome, congenital anomalies was not meta-analyzed. Congenital anomalies are among the three most common causes of infant and early child mortality , and in milder cases often a challenge for the individual, his/her family, and for the society.
Currently, a substantial proportion of women who give birth in Europe are not born in Europe; in fact, the proportion of women who are born outside the country in which they give birth exceeds 25% in most countries . The concept of “migrants” covers a hugely diverse population, which differ from country to country and with great differences within each country. In Brussels, Belgium, around two-thirds of new mothers are migrants, many of whom are well-off migrant workers from other European countries. In most countries, however, the migrant groups are dominated by those from low- and middle-income countries and refugees from war zones.
In this paper, we address the contemporary reproductive health among migrants in Europe with respect to stillbirth and congenital anomalies. First, we describe the risk of stillbirth and congenital anomalies in offspring of migrant women, if possible as characterized by their country of origin, as reported in the literature. Then, we address some suggested causal factors with particular focus on the role of consanguinity. Finally, we briefly discuss possibilities for improvement of the situation in the future.
Stillbirth risk in migrants in Europe
In a study that covered birth in Norway between 1967 and 1993, Stoltenberg et al. reported that women from Pakistan had a high risk of stillbirth as compared to Norwegian women , and this tendency has been confirmed in a recent study, covering the period 1995–2010, where women who migrated to Norway from Pakistan had a 2.8 times higher risk of stillbirth than Norwegian women . Women of non-Western background had even higher relative risks for stillbirth in twin pregnancies compared to Norwegian mothers . In another study, it was reported that the other large migrant group in Norway, the Vietnamese, had a lower perinatal mortality than the Norwegian majority population . The Danish nation-covering registers were used to assess risk of stillbirth according to maternal country of origin. The stillbirth risks in the five largest non-Western minority groups, defined by country of birth, were compared to the risk in the majority (Danish-born) population. Women from Pakistan, Somalia, and to a lesser extent Turkey had an increased risk of stillbirth, and this excess risk was not mediated through income or educational level . In this study, the large Lebanese migrant group, vastly representing Palestinian refugees, had the same stillbirth risk as the majority population. A study from Flanders, Belgium, reported that migrants from low- and middle-income countries had, respectively, 2.7 and 1.5 times the native-born women’s risk of stillbirth during 2004–2008, while migrants from high-income countries had no such increased risk . Another study from Brussels, Belgium, demonstrated that migrants from North Africa (the Maghreb), Egypt, Turkey, and sub-Saharan Africa had an almost doubled risk of stillbirth than Belgian-born women and the rest of the Europe-born women . In Spain, in 2007–2010, it was reported that women born in Africa had an almost doubled risk of stillbirth as compared to Spanish women, while women who migrated from Europe, the Americas, and Asia to Spain had the same risk as Spanish-born women . Analyses from the region of Valencia demonstrated a particularly high risk among women from sub-Saharan Africa and Eastern Europe, but not in the largest migrant group: women from Latin America . A nation-covering study from Germany including all births from 2004–2007 demonstrated an increased risk of stillbirth for women from the Middle East and North Africa (RR = 1.3), while no statistically significant increased risks were found for women who migrated from Asia, Europe, or North America . A register-based study from Sweden demonstrated that stillbirth risk was substantially increased in women from the Middle East and Africa, but not in women who migrated to Sweden from other parts of the world . A study of deliveries in Malmoe, Sweden, from the 1990s emphasized the particularly high rate of perinatal mortality in women from sub-Saharan Africa . An older study from UK compared perinatal mortality in women with, respectively, UK, India, Bangladesh, and Pakistan as country of birth. Independently of maternal age and parity, the offspring of women of Pakistani origin had an approximately doubled risk of perinatal mortality as compared to UK mothers. The offspring of Indian and Bangladeshi mothers also showed increased mortality, but to a lesser degree .
A cross-country analysis of stillbirth risk in Turkish mothers compared to the majority population mothers demonstrated that in all of the eight European countries examined, the Turkish mothers had an increased risk of stillbirth, with odds ratios (ORs) within the range 1.1–1.6. The authors concluded that the variations in Turkish women’s stillbirth risk between countries indicated that preventable society-specific determinants contributed to the fetal mortality.
Overall, the studies reflect heterogeneity, in accordance with the conclusion of another review including all the industrialized countries in Europe . We find most consistency in the following findings: mothers from refugee countries were not particularly vulnerable to stillbirth and many studies report increased stillbirth risk for migrants from Pakistan, Turkey, and sub-Saharan Africa.
Stillbirth risk in migrants in Europe
In a study that covered birth in Norway between 1967 and 1993, Stoltenberg et al. reported that women from Pakistan had a high risk of stillbirth as compared to Norwegian women , and this tendency has been confirmed in a recent study, covering the period 1995–2010, where women who migrated to Norway from Pakistan had a 2.8 times higher risk of stillbirth than Norwegian women . Women of non-Western background had even higher relative risks for stillbirth in twin pregnancies compared to Norwegian mothers . In another study, it was reported that the other large migrant group in Norway, the Vietnamese, had a lower perinatal mortality than the Norwegian majority population . The Danish nation-covering registers were used to assess risk of stillbirth according to maternal country of origin. The stillbirth risks in the five largest non-Western minority groups, defined by country of birth, were compared to the risk in the majority (Danish-born) population. Women from Pakistan, Somalia, and to a lesser extent Turkey had an increased risk of stillbirth, and this excess risk was not mediated through income or educational level . In this study, the large Lebanese migrant group, vastly representing Palestinian refugees, had the same stillbirth risk as the majority population. A study from Flanders, Belgium, reported that migrants from low- and middle-income countries had, respectively, 2.7 and 1.5 times the native-born women’s risk of stillbirth during 2004–2008, while migrants from high-income countries had no such increased risk . Another study from Brussels, Belgium, demonstrated that migrants from North Africa (the Maghreb), Egypt, Turkey, and sub-Saharan Africa had an almost doubled risk of stillbirth than Belgian-born women and the rest of the Europe-born women . In Spain, in 2007–2010, it was reported that women born in Africa had an almost doubled risk of stillbirth as compared to Spanish women, while women who migrated from Europe, the Americas, and Asia to Spain had the same risk as Spanish-born women . Analyses from the region of Valencia demonstrated a particularly high risk among women from sub-Saharan Africa and Eastern Europe, but not in the largest migrant group: women from Latin America . A nation-covering study from Germany including all births from 2004–2007 demonstrated an increased risk of stillbirth for women from the Middle East and North Africa (RR = 1.3), while no statistically significant increased risks were found for women who migrated from Asia, Europe, or North America . A register-based study from Sweden demonstrated that stillbirth risk was substantially increased in women from the Middle East and Africa, but not in women who migrated to Sweden from other parts of the world . A study of deliveries in Malmoe, Sweden, from the 1990s emphasized the particularly high rate of perinatal mortality in women from sub-Saharan Africa . An older study from UK compared perinatal mortality in women with, respectively, UK, India, Bangladesh, and Pakistan as country of birth. Independently of maternal age and parity, the offspring of women of Pakistani origin had an approximately doubled risk of perinatal mortality as compared to UK mothers. The offspring of Indian and Bangladeshi mothers also showed increased mortality, but to a lesser degree .
A cross-country analysis of stillbirth risk in Turkish mothers compared to the majority population mothers demonstrated that in all of the eight European countries examined, the Turkish mothers had an increased risk of stillbirth, with odds ratios (ORs) within the range 1.1–1.6. The authors concluded that the variations in Turkish women’s stillbirth risk between countries indicated that preventable society-specific determinants contributed to the fetal mortality.
Overall, the studies reflect heterogeneity, in accordance with the conclusion of another review including all the industrialized countries in Europe . We find most consistency in the following findings: mothers from refugee countries were not particularly vulnerable to stillbirth and many studies report increased stillbirth risk for migrants from Pakistan, Turkey, and sub-Saharan Africa.
Risk of congenital anomalies in children of migrants in Europe
A >25-year-old study of perinatal mortality among migrants to England and Wales from the Indian subcontinent demonstrated a three times higher risk of perinatal death from congenital anomalies in mothers from Pakistan, much higher than the likewise increased risk found for mothers from India and Bangladesh .
In a recent paper published in The Lancet, the risk of congenital anomalies was investigated in the multiethnic Born in Bradford cohort . Compared to “White British” ethnicity, children of Pakistani origin had an almost twice as high risk and the heterogeneous “Other” group had a 22% higher risk of congenital anomalies. Children of Pakistani mothers also had a particularly high risk of infant death due to congenital anomalies .
In a Danish study, an excess risk of infant mortality due to congenital anomalies was found for offspring of Turkish-, Pakistani-, and Somali-born women and this was also found in a study of mortality in children <5 years of age . An analysis from Belgium, investigating the three largest non-European migrant groups, revealed that women from Morocco and Turkey, but not sub-Saharan Africa, had significantly increased risk of perinatal mortality due to congenital anomalies . The study conducted in Valencia indicated that migrants as a large, heterogeneous group had an increased peri- and neonatal mortality due to congenital anomalies .
Essén’s study of all births in Malmoe from 1990 to 1995 revealed no difference in severe congenital anomalies between offspring of Swedish- and foreign-born mothers, but the prevalence of severe congenital anomalies was very low (0.2%) and a very restrictive definition must have been used .
In an analysis of temporal changes in ethnic perinatal health disparities in Berlin, it was reported that Turkish women had an increased risk of giving birth to a child with a congenital anomaly in 1993–1997, but interestingly no increased risk during the period 2003–2007 .
A large nation-covering study from the Netherlands compared cause-specific infant mortality in offspring of Dutch and the four major immigrant group mothers: Turkish, Moroccan, Surinamese, and Antillean/Aruban. Compared to offspring of Dutch mothers, children of Turkish and Moroccan mothers had a significantly increased risk of infant death from congenital anomalies, which was not the case for children with Surinamese and Antillean/Aruban origin .
In summary, the findings resemble those for stillbirth with respect to heterogeneity, but there may be a pattern indicating increased risk in women who migrated to Europe from the Middle East, North Africa, and Pakistan.
What are the reasons for the increased fetal mortality and congenital morbidity among migrants in Europe?
It is evident from the heterogeneity in risk that a number of factors contribute to this increased mortality and morbidity. Three main causative factors are at play. First, there are strong social inequalities in stillbirth risk, and the apparently ethnic disparity could in fact be a socioeconomic disparity. Consanguinity is also often mentioned as a causative factor, as marriage between people who have grandparents or great grandparents in common is frequent in many of the countries from where present-day migrants in Europe originate. Suboptimal pre- and perinatal health care for migrants is also often suspected to account for the increased mortality and morbidity.
Do we mix up the categories: migrants and poor social conditions?
This is a highly relevant question in terms of stillbirth. There are strong social inequalities in stillbirth risk in high-income countries , and migrants in European countries are, on average, socioeconomically disadvantaged.
A study of all births in Rotterdam in 2000–2007 addressed this issue by comparing pregnancy outcomes in Western and non-Western women according to a composite measure of neighborhood social index with four strata (SI). In Rotterdam, mothers of non-Western origin contribute to almost half of the births, and the distribution between Western and non-Western mothers by SI was markedly skewed. While perinatal mortality was higher in non-Western women, a strong social gradient in perinatal mortality was found in Western women with no such gradient in non-Western women .
In the Swedish study of stillbirth risk, it was concluded that the increased risk of stillbirth was unaffected by adjustment for socioeconomic factors and maternal morbidity , but the authors found that the duration of residence in Sweden was inversely related to stillbirth risk.
The Spanish study demonstrated that the stillbirth risk was almost twice as high in lower-educated women than in higher-educated women, and that the risk for the quartile of women living in the autonomous regions of Spain with the highest unemployment percentage was 2.6 times higher than the risk of the quartile of women living in the regions with the lowest unemployment. Adjustment for individual educational attainment and contextual unemployment did not, however, reduce the excess risk of stillbirth for African women , and an analysis of the multiplicative interaction between maternal educational attainment and country of origin confirmed this finding . In the Danish study of stillbirth in different migrant groups in Denmark, we attempted to adjust for the socioeconomic situation of the parents (as measured by household income and educational attainment) to determine whether the ethnic differences in risk of stillbirth could be explained by differences in a socioeconomic situation. Notably, the adjusted risk estimates only attenuated marginally. We repeated the analyses, restricting the population to those in the upper 50 percentile of income and longest educational group, respectively, and found further increased risks of stillbirth in the migrant groups from Pakistan, Turkey, Lebanon, and Somalia .
This was in sharp contrast to the finding from Flanders, Belgium, where adjustment for maternal age, parity, and educational level eliminated the increased risk of stillbirth found in the crude analyses .
The risk of confounding from socioeconomically patterned factors is less when it comes to congenital anomalies. In contrast to the case of stillbirth, the evidence for social patterning of congenital anomalies is not very strong, although newer studies indicate a growing socioeconomic disparity in congenital anomalies . This argument is in line with the study from Brussels that investigated the cause of mortality and reported that particularly congenital anomalies accounted for the excess perinatal mortality in Turkish and North African mothers, independent of socioeconomic status .
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